Medicare Introduces AI to Review Coverage Decisions in 6 States
Medicare is testing a new way to decide whether certain medical treatments are necessary, and it marks a notable shift for the program. For the first time, artificial intelligence is being used to help review coverage decisions for people enrolled in Original Medicare in six states.
Supporters frame the move as a way to reduce waste, while critics warn it could slow care and add pressure on physicians and patients alike.
The federal government launched this effort under the Trump administration through a pilot initiative called the Wasteful and Inappropriate Service Reduction (WISeR) Model. The program is now active in: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
The pilot is expected to run for at least six years, making it more than a short-term test. Health policy experts say the length of the program signals that Medicare is seriously exploring long-term changes to how care approvals work.
What the WISeR Model Is Designed to Do
YouTube | CMSHHSgov | CMS Administrator Dr. Mehmet Oz launched the WISeR Model to aggressively combat Medicare fraud and waste.
At its core, the WISeR Model introduces prior authorization into parts of Original Medicare using artificial intelligence. Prior authorization requires doctors to receive approval before providing certain treatments. While this process is common in Medicare Advantage plans, it has been rare in traditional Medicare, according to KFF, a health care policy research and news organization.
Under this model:
1. AI systems flag claims for certain services
2. Any denial made with AI support must still be reviewed by a human clinician
3. The focus remains on identifying services considered unnecessary or overly costly
The Centers for Medicare and Medicaid Services (CMS) has tied the program closely to cost control and fraud prevention. CMS Administrator Dr. Mehmet Oz said the agency “is committed to crushing fraud, waste, and abuse,” adding that the WISeR Model aims to “help root out waste in Original Medicare.”
Dr. Oz also described the initiative as a modernization effort. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures,” he said.
Treatments and Services Under Review
The WISeR Model currently targets 17 specific items and services. These include treatments that Medicare officials say have a higher risk of being overused. Among these are knee arthroscopy procedures for arthritis, electrical nerve stimulation devices used for various conditions, and certain treatments for impotence.
Medicare enrollees receiving these services may now see their care reviewed through this new AI-assisted process before coverage is approved.
Why Physician Groups Are Raising Concerns
Medical organizations have reacted strongly to the pilot. The American Medical Association (AMA) called the use of AI in Medicare care decisions “a significant departure from current standards.”
Physicians and medical students, represented by national associations, also pointed out that CMS had previously secured a commitment from health insurance providers to reduce prior authorization requirements. They said the WISeR Model “seems to conflict” with that earlier agreement.
The AMA has long argued that prior authorization creates delays and administrative strain. In a letter sent to CMS last year, the organization described prior authorization as “one of the most burdensome and disruptive administrative requirements” physicians face when trying to deliver quality care.
Data That Highlights the Patient Care Impact
Freepik | The WISeR pilot examines the tension between tech-enabled austerity and the necessity of immediate care.
Concerns from doctors are backed by recent data. In a 2024 AMA survey, physicians reported widespread negative effects tied to prior authorization:
1. 93% said it causes delays in patient care
2. 82% said it can result in patients not receiving treatment at all
3. 29% linked prior authorization to serious adverse events, including hospitalization, disability, or death
The association warned that adding these protocols to Traditional Medicare could increase practice costs, pull attention away from patients, and create avoidable delays.
According to the AMA, “The introduction of such PA protocols in Traditional Medicare only risks creating unnecessary delays in patient care, increasing practice expenses, and diverting time and resources away from direct patient care.”
Prior Authorization Changes Outside the Pilot
Although Alabama is not part of the WISeR Model, the issue of prior authorization has drawn attention there as well. Last year, the state’s largest health insurer committed to reforming its process, including changes affecting Medicare Advantage enrollees.
In November, Blue Cross and Blue Shield of Alabama announced updates: AI will no longer be used for claim denials, patients with chronic conditions will have less paperwork, and physicians with strong approval records will be exempt from standard prior authorization under a new “gold card” program.
Dr. Darrel Weaver, vice president of provider engagement and support at Blue Cross and Blue Shield of Alabama, said in a statement that the insurer values its relationship with physicians. “These updates reflect our ongoing efforts to improve the member and provider experience while maintaining responsible stewardship of healthcare resources,” he said.
The WISeR Model places Medicare at a crossroads between technology-driven oversight and long-standing concerns about access to care. Supporters see potential savings and tighter controls on unnecessary treatments. Critics remain focused on delays, added workload, and patient risk.
As the pilot continues across six states, its results are likely to shape how Medicare balances cost control with timely medical care for older adults across the country.